May 22, 2012

My Take on the Future of Geriatrics

I was in the midst of a 3-week geriatrics elective when I curiously read Is Geriatric Medicine Terminally Ill?, an article in the American College of Physicians (ACP) publication, Annals of Internal Medicine. In short, the article stated that since its creation in 1988, the field originally created to care for the complex medical needs of aging patients has struggled to attract and retain physicians, owing to issues such as “futility of care,” and “lack of remuneration.”

I was absolutely blown away. My knowledge of and interest in the field of geriatrics had only grown during my rotation, and I was both impressed and inspired by the genuine love and dedication my attending physicians and geriatric fellows demonstrated on a daily basis. I was both floored and amazed by the tact, sensitivity, and candor the physicians displayed when discussing particularly difficult subjects. I learned early on that end-of-life conversations, and malignancy treatment planning were something commonplace in the geriatrics clinic. I even became comfortable discussing subjects like advanced directives and living wills on my own.

Not only was the rotation educational from a patient-interaction perspective, but it was also incredibly eye-opening from a health-systems perspective. In addition to the geriatric clinic, I was required to spend part of my rotation in an acute rehab facility, as well as in a long-term living which featured all levels of care- from independent living to hospice. I took part in a number of interdisciplinary team appointments, including falls assessments, comprehensive geriatric assessments, and geriatric oncology planning. First-hand exposure to the coordination of care between inpatient and outpatient settings, as well as interdisciplinary team participation is something that few medical students are able to experience, and I believe I walked away from the rotation with both a wealth of practical and academic knowledge that will one day improve my ability to care for and communicate with my patients.

It turns out that I am not the only one who was alarmed by the ACP piece. When reading more into the subject, I not only read a number of snarky responses, but also quickly learned that Geriatrics will be officially entering the 2014 National Residency Match Program (NRMP) as a fellowship, rather than as a Certificate of Added Qualifications. Given the increasing health care costs and strain created by the aging population, it is clear that there is a concrete need for physicians trained in this field… in fact, perhaps ALL physicians should be familiar with the particular concerns of elderly patients, at least to some degree. In either case, I found most of the assertions of the ACP piece to be far from applicable to my wonderful attending physicians and fellows, and would highly recommend a rotation or elective in geriatrics to any medical student.

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April 18, 2012

The Little Things I Wish I Knew Before I Was Set Loose on the Wards

When I was asked to write some advice for rising MSIIIs, I had to take a step back; after all, I still have nearly 12 weeks left in my own 3rd year and  feel as though I haven’t truly mastered it. Regardless, while brainstorming for tricks and tidbits to pass a long, I ended up reflecting on some of the major take-home points I’d garnered from each of my rotations. In the end, I realized it was the “little things” that had the biggest impact on my experiences, and thus, my grades.

I began my year in July on internal medicine. It was a great first block for a couple of reasons – I was fresh off of Step 1, so it was easy to recall the basic sciences and pathophysiology that come up frequently in during rounds. It is where I learned how to really “be a medical student.” I learned how to write a good SOAP note, and how to present patients succinctly during teaching rounds. I quickly realized that I needed to buy a pocket pharmacology reference, because the clinical pharmacology my residents talked about was very different from the way I had learned it during second year. I  filled out discharge paperwork and wrote sign-outs. I found that if I was able to know a little about every patient on our service, I could offer help with paperwork or calling consults. These are the types of things the residents really appreciate, and that will get everyone finished a little bit earlier at the end of the day.

After medicine, I went into my pediatrics rotation feeling well-prepared. I could now write detailed notes, and was learning how to “speak doctor.” I quickly found that the detailed, verbose presentations expected of me during my medicine rotation were unappreciated here; instead, I learned to convey the same message using simpler terms, which were much more reassuring to anxious parents. As a side, I ended up on the pulmonology team at the children’s hospital and really got to know my lung sounds.

I have to admit that my 3rd year schedule was an ideal learning curve, because I had already “completed” 2/3 of Family Medicine. While I lacked some OB/GYN experience, I was able to showcase the knowledge I’d accumulated regarding both adult and pediatric medicine. At my community clerkship site, I was given the opportunity to perform multiple procedures. I jumped at the opportunity to perform pelvic exams and was able to participate in labor and delivery. While demonstrating my initiative to the team, I also was getting some extra help in preparation for my next rotation.

OB/GYN is one of the rotations that students notoriously “just want to get through.” The residents work long, stressful hours, and may be difficult for some to interact with. Personally, I’m the type of person who would rather be busy than bored or angry, so  I actively participated and learned. I asked questions. I scrubbed into every C-section I could and brushed up on my surgical skills. Most importantly, I took every available opportunity to deliver babies. I was thrilled when a family wrote me a thank – you note after I helped coach them through a long labor, and it was what the residents remembered when it came time to write my evaluation.

The hallmark of my psychiatry rotation was learning how to obtain good collateral information. I had to forget what I learned in other rotations about being succinct – I spent hours pulling up hospitalization records and tracking down family members to help my team really understand what was going on with each patient. I set aside my stethoscope for the mental status exam and MOCA (Montreal Cognitive Assessment) test. In fact, I still have a stack of MOCA’s  that I carried in my white coat laying on my shelf.

Currently, I’m learning the ins-and-outs of surgery. However, I’ve already found that preparedness goes a long way. Reading about upcoming cases and carrying 4×4′s, steri-strips, and suture removal kits on rounds has proved helpful. I’ve quickly learned to befriend the scrub nurses in the OR – I get out my own gown and gloves, help hook up machines, and get the patient warm blankets. With evaluations still floating amongst the residents, my cursory assessment is that once again, it’s the little things that are most appreciated and end up paying off.

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March 21, 2012

Happy One-Year Blogo-Versary!

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I am proud to say that April 1st marks the official one-year anniversary of www.md2bgrecoa3.com! During the year, I’ve learned a lot about myself, defined my future career goals, made some wonderful professional connections, and most importantly, have been able to fully explore and unite two of my favorite interests – media and medicine.

One of my original goals in the creation of my blog was to explore the utility of social media in the practice of medicine and in medical education. I found it disheartening that this incredible technology was too often shunned by members of the medical profession. I wanted to prove that as a medical student, I could maintain a professional and useful social media presence.

After one year, I am ecstatic to say that I have done just that.

As a member of the Class of 2013, it is now my turn to step up to the plate and begin to prepare my residency application. Quite frankly, I wasn’t sure how to address my social media presence when it came to my CV. How do I direct residency selection committees to my blog, when social media is frowned upon by so many? When brainstorming for personal statement ideas, I found myself thinking, “there’s more personal-statement-worthy material in my blog than I can ever put into a one-page essay.” Non-medical friends and family proudly display LinkedIn contacts, Twitter handles, and websites on their resumes and job applications, so why can’t I?

Actually, I can. And I did.

And the reaction was not something I would have expected one year ago.

I’ve spent the last month meeting with career and academic advisers, all of which have incredibly supportive of my social media involvement. They asked questions and pulled up my blog and twitter feeds on their own computers. They suggested incorporating all aspects of my social media presence into my personal statement and applications to help me stand out in the applicant pool. One supervising physician even gave me the contact information for local news media offices and suggested petitioning the registrar to receive credits for a 4th-year internship in health news and media.

One particular comment that I received in these meetings really stood out as a testimony to the future of #hcsm (that is, the Twitter code for health care social media) and solidified the progress made during this one year alone. It went something like this:

“Doctors – especially us older docs – just don’t know what to do with social media. Everyone else is out there using it but we can’t really figure out how to make it work for us. This is exactly what we need, especially in academic programs – people who are comfortable dealing with it to help teach the rest of us and make it work.”

Here’s to health care social media, and all those blogging, tweeting, Facebooking, and otherwise social-networking students and physicians who have helped pave the way for the rest of us!

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February 18, 2012

“So, Do You Know What You Want to Do?”

Every career has that one question that is notoriously hated by all. For nurses, that question is, “So, why didn’t you want to be a doctor?” For teachers, it’s questions about the age-old adage, “Those who can’t do, teach.” For medical students, that question is, “So, do you know what you want to do?”

It’s not that people who ask medical students about their career plans are ill-intentioned or nosy; in fact, the question seems like natural small talk to non-medical folk.  The truth is, it’s an extremely overwhelming and personal decision. Medical students are exposed to only a few week of core specialties within the 3rd year – internal medicine, pediatrics, family medicine, surgery, obstetrics and gynecology, and psychiatry- with little or no exposure (depending on curriculum) to the many other career options. And while the final decision is somewhat negotiable, medical school and residency is, quite frankly, a long and expensive haul that does make a do-over all that appealing.

While the input and approval of friends and family may be respected and appreciated, the answer to the question becomes much more difficult when a resident or attending physician is doing the asking. It’s not so easy to tell the person who grades you that you want nothing to do with his or her own profession. On the other hand, its the good and bad experiences that you have with your attending, residents, and other team members that can really make or break your career choice.

At least, that’s what happened to me.

I came to medical school convinced that I would go into rural family medicine. I had worked in my father’s internal medicine practice during summers and vacations, and adored his patients and the family atmosphere. I also loved working with children, and carried an interest in women’s health. I figured I could be a great addition to his practice one day.

When 3rd year rolled around, my thoughts became more jumbled. Internal medicine was my first rotation. It took some time to adjust to the ins-and-outs of 3rd year clerkships, but I enjoyed the rotation. I was immediately drawn to the art of bedside rounding and teaching rounds, and knew immediately that teaching could be a way to integrate my communications background into my medical career. I did a stint in the stroke unit, which I found incredibly challenging and exciting.  I was surprised to realize that I didn’t actually love pediatrics. I had fun and learned a lot, but I found managing childhood illness less exciting than managing the care of adults with multiple commodities. I had similar thoughts about obstetrics and gynecology; I also didn’t love the time I spent in operating room during the rotation.

The “make-it-or-break-it” moment actually happened during my family medicine rotation. During the clerkship, I was able to experience both inpatient and outpatient family medicine. While I enjoyed the outpatient portion of the rotation, I found myself thinking about the patients on the wards. I missed the pace of inpatient medicine, and missed morning teaching rounds. I realized that I loved the challenge of working with and caring for sick patients, and watching their health improve from day-to-day. I also loved the beauty of the physical exam. During my time on inpatient services, I could actually see and appreciate the physical findings I had previously only read about.

And the rest is history…

..sort of. My journey is really only just getting started. I have no idea whether I want to go into hospital medicine, pursue a fellowship in one of the internal medicine sub specialties, or work in a critical care unit. I know that teaching is definitely in my future, and have decided to look into residencies at university hospitals to help me achieve this goal. But, most importantly,  after nearly 3 years of medical school under my belt, I am happy to announce that I am officially ready to start applying for residency!

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January 22, 2012

“Let’s Take a Minute for the Time Out”

If you’ve ever spent time in the Operating Room, you are already familiar with the words the circulating nurse uses to signal the Time Out – the few minutes before a procedure begins when the surgical and anesthesia teams review a patient’s case. If you’re a non-medical type, or a medical student whose surgical rotations are scheduled late in the 3rd year, then you’re just as clueless as I was when I stepped into the operating room for the first time.

In reality, I didn’t so much step as I did tiptoe. And actually, I probably looked more like some sort of gunslinger – with my back to the corner, trying not to be noticed, and taking in my surroundings. Dressed head-to-toe in a light blue ghillie suit; a sterile light blue ghillie suit.

I was terrified.

I heard horror stories from other students about surgeons and scrub nurses yelling at medical students who didn’t use proper aseptic technique; understandable, considering that one tiny misstep could expose the patient to bacteria and increase their risk for infection and post-operative complications. I had been oriented to the goings-on in OR the previous day; all the “Do’s” and “Dont’s” about the choreographed dance more commonly known as “scrubbing” – properly cleaning my hands, putting on a sterile gown and gloves, and walking around on the OR to prevent contamination – were running through my head as jumbled words and phrases while the rest of the team respectfully stood in total silence. The circulator read the Time Out checklist, listing the patient’s allergies and anticipated complications, and naming the antibiotics that had been given. As the Time Out ended, each team member set in motion, creating  a sort of organized chaos where everyone goes in a different direction, each with a prescribed role.

Everyone but me.

There was no magical moment where everything suddenly came together and I saw an existential light calling me into the field of surgery. But as  the rotation progressed, I became more comfortable with my role as part of the surgical team. There were understanding, patient, and helpful nurses who showed me where to stand so I could see the surgical field and whispered instructions in my ear about what I should do to assist the surgeon. Sure, once I got reprimanded for bumping into a sterile table, but I learned that I wasn’t the first or last person (medical student or otherwise) to do so. There were incredible cases, and robotic surgeries that were so amazing I can’t imagine ever describing them as less than extraordinary. Once, I was asked to place my hand into the incision. I remember being totally awestruck and thinking, “Who would let me put my hand into a living, breathing human being?”

In reality, I was retracting subcutaneous fat. Never has a medical professional ever been so excited about fat.

I began to appreciate the beauty of the Time Out – those short few minutes where the chaos of the operating room came to a standstill, when the entire team reflected on the life before them, and the procedure they were about to perform. With that said, I can’t perpetuate any of those horror stories that I’d heard when I started my rotation. The advice I can offer is that no matter the rotation, there will always be situations that are uncomfortable or intimidating. In those situations it is important to take a “Time Out,” to focus on the aspects of the rotation that you enjoy or find intriguing. These are what will make your experience worthwhile.

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December 20, 2011

My New Years Resolution is to Become a Better Advocate for My Patients

During my recent Family Medicine rotation, I attended an informal lecture about advocacy. I’d been exposed to the concept advocacy in the past, particularly in my pediatric rotation, but those advocacy sessions primarily involved sharing information about the various community organizations and resources that were available to our patients – Woman, Infants, and Children (WIC), Child Protective Services (CPS), Department of Family Services (DFS), Supplementary Security Income (SSI), State Children’s Health Insurance Program (SCHIP), breast-feeding support groups, etc. There was also an awareness of the need for physician advocacy on other levels – within the media, as lobbyists, as community leaders.

Personally, I’d never much cared for learning history or any sort of political science. Admittedly, I’ve been trying to read up on the topic as of late, considering how overwhelming the discussions on health care reform have become and how dramatically this legislation will affect my future career. I can follow a conversation about SGR and the RUC, and understand why these things are generally bad for our current health care system. I think I have a relatively good handle on how insurance programs like Medicaid and Medicare are funded, and how changes to these programs will affect both my patients as well as physician reimbursements. I can’t cite statistics or really go into nitty-gritty detail, but I feel confident enough to take a stance on these issues and get involved.

The more unfortunate reality is that medical students and residents are rarely afforded the time to take action for or against any of these issues. This brings me back to my recent advocacy lecture.

Rather than talking about a generic need for advocacy, the speaker gave us concrete explanations about how even medical students could find, access, and lobby to a congressperson. At the simplest and most basic level, we were directed to the websites of physician organizations such as the American Medical Association (AMA) and the American Academy of Family Practice (AAFP). These sites have pages dedicated to lobbying state and national government leaders for or against the special interests of the respective organization. Topics such as SGR and Medicare are hot right now, but the sites (and the issues) are updated frequently. Simply plugging in a name and address can generate an email, letter,  or script for a telephone call to one’s senator or representative.

These national and state physician interest organizations are also a resource for identifying the appropriate senator or representative regarding more specific advocacy issues. A message will be heard more clearly if it is addressed to a congressperson who sits on a committee or writes a bill that addresses the concern. That congressperson is also more likely to pay attention to the message if its author is a constituent who can offer (or refuse) support in an upcoming election; thus, it is important to reach out to local and state leaders. With that said, one should choose a direct subject heading that lets the reader know exactly `what bill, topic, or issue the letter or email relates to. The message becomes more concrete if it contains a personal story; these are the accounts that we hear about in campaign speeches and political debates. It is important to remember to add these types of anecdotes to even generic, generated letters and e-mails.

Finally, there are days set set aside “on the Hill,” where special interest groups can raise awareness for their concerns. During these times, senators and representatives (or their office staff) may be available to meet in person about specific topics. Again, it is important to address concerns to the appropriate congressperson, and also helpful to provide a hard copy of the concrete changes or topics that need to be addressed. However, one needs to recognize that nothing tangible may come out of what will probably be a very brief encounter.

I’d always pictured myself as a media-type advocate; I’d like to write news articles or Op-Ed pieces about issues that I think are important for my patients to be aware of. Even that idea has sort of a “when-I-grow-up” sort of vibe to it, considering I have no idea what type of physician I want to be, or what sort of patient population I’ll serve. However, I thought it was extremely helpful to know there are little ways that even the most politico-illiterate and time-crunched medical students can get involved. With that said, I think I know what my New Year’s Resolution will be.

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December 3, 2011

A Community of Medical Education

As I have mentioned in previous posts, I am a member of my medical school’s Physician Shortage Program. The program, which does not involve any long-term primary care commitment or loan repayment, is made up of a group of students, primarily from rural hometowns, who are interested in pursuing medical careers in undeserved and/or rural communities. We meet as a group and discuss our personal experiences growing up in rural areas, the challenges faces by community physicians, and the proposed and impending legislature that will affect the practice of medicine in these areas. As part of this program, I was able to participate in a community medicine rotation, something few students at my institution get to experience during their third year.

Before I can elaborate on my experiences during this rotation, I would be amiss if I didn’t mention the structure of my institution’s third year clinical clerkships as a whole. Normally, students are expected to complete six-week rotations each in Pediatrics, Family Medicine, OB/GYN, and Psychiatry. We are also required to complete 12-week surgical and medical rotations, which include time spent in neurology as well as two other electives. All of these required courses must be completed at institutions affiliated with our teaching hospital, a large, urban academic center in Philadelphia primarily serving inner city patients. As a rule, “away” rotations at hospitals and practices not affiliated with this hospital are not allowed until fourth year.

My family medicine rotation, however, took place at a community hospital and its associated resident clinic located about 2 hours away from the familiar bustle of Philadelphia. While my peers would spend six weeks together, completing an entirely outpatient-based rotation, I would be the only student from my class of 250 on this particular rotation, and had absolutely no idea what to expect. As it turned out, the rotation was the most thoughtfully organized and coordinated clerkship that I have completed thus far.

The outpatient program’s main strength came from its small size and large geographic coverage. The hospital and its associated resident clinic provided care to patients from all walks of life – the insured, uninsured, wealthy, and those in need. My six-week schedule was divided between outpatient and inpatient services, so I learned very quickly how busy these services were. In fact, because of the number of appointments scheduled a the resident clinic, I was able to take on my own patient load during the outpatient portion of my rotation; I saw and precepted these patients as if I was one of the residents myself! Additionally, during the outpatient portion of my rotation, I was able to work at a private family medicine practice a few miles away from the hospital, and got a glimpse of life in community family medicine after residency.

The inpatient service was equally as hectic. While there was a respected OB/GYN practice in the area, when it came to obstetrics care, many of the woman wanted their family doctor to be there with them in the delivery room. Likewise, emergently-ill patients expected to see a familiar face when they arrived in an ambulance. As if the service those factors alone didn’t keep the inpatient service busy enough, an expertly run EHR system allowed us to coordinate and plan follow up appointments in the resident clinic after discharge. This coordination of care was the epitome of “patient-centered.”

The most striking observation I made about medical care, particularly within this community, was the lack of support from psychiatrists. Even patients desperately in need of this type of care were forced to wait months for a cancellation so they could be put on a psychiatrist’s schedule. The family practitioners were forced to single-handedly manage conditions that I had only imagined I would see during a psychiatric rotation. It was truly the physician shortage at its finest.

I still have two more weeks left on my community medicine rotation, but I feel like I’ve already been exposed to so much more than my peers who have spent the last few weeks in an entirely outpatient-based, urban practice. While I’m sure many of the same challenges exist for family practitioners across both settings, I feel as though my rotation has given me a better handle on what my life will be like both as a resident and as a practicing physician. I am fortunate to have been given this opportunity so early in my medical education, and would recommend this type of elective to any medical student, particularly if he or she is considering it as a career choice.

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